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Ablation Strategy
In brief, our strategy for initial ablation has been uniform and consisted of PVAI plus targeting of nonpulmonary vein triggers of AF that could be provoked with incremental doses of isoproterenol (3, 6, 12, and 20 μg/min) and/or burst pacing to provoke AF followed by cardioversion with and without low-dose isoproterenol (2–3 μg/min). A trigger was defined as AF, organized atrial tachyarrhythmia, or atrial premature depolarization (APD) originating from the PVs. A non-PV trigger was defined as a source of repetitive and reproducible atrial premature depolarizations (APDs) that triggered AF or sustained atrial tachycardia. Cavotricuspid isthmus ablation was performed if typical atrial flutter was documented clinically or induced in the lab.
Dual transseptal punctures were performed guided by intracardiac echo (ICE) and fluoroscopy. A preprocedure cardiac CT scan or MRI was typically performed and merged together with the 3D electroanatomic map. A multipolar circular catheter (Lasso, Biosense Webster, Diamond Bar, CA, USA) catheter was used to assess for PV reconnection. All PVs were isolated with an endpoint of entrance and exit block. All isolated PVs were revisited after 30 minutes to ensure durable entrance and exit block. Patients with acutely reconnected PVs underwent reisolation of the reconnected regions and ablation of non-PV triggers when present.
At time of repeat ablation, the same mapping and stimulation protocol was utilized to identify regions of chronic PV reconnection using the multipolar circular catheter at the antrum of each PV. Reconnected segments were reisolated to reestablish entrance and exit block. Isoproterenol infusion was repeated to provoke and identify any additional triggers. After 2012, intravenous adenosine 12–18 mg was routinely used at the time of repeat ablation to further assess for PV reconnection.
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